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Frattaroli FM, Carrara A, Conte AM, Pappalardo G. Axillary Metastasis as First Symptom of Occult Breast Cancer: A Case Report. TUMORI JOURNAL 2018; 88:532-4. [PMID: 12597153 DOI: 10.1177/030089160208800620] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Axillary lymph node metastasis from an occult breast carcinoma is a rare occurrence. We report this condition in a 59-year-old woman who presented with a swelling in the right axilla. No breast mass was clinically evident. Mammography, ultrasonography and multiple random fine-needle breast biopsies yielded no pathological findings. No extramammary primary lesions were present. Axillary sampling was performed and histological examination revealed the presence of metastatic adenocarcinoma in three of the 12 dissected lymph nodes. Estrogen receptors were positive and immunohistochemistry pointed to a breast origin. All these data were suggestive of occult breast cancer. The patient refused any further treatment but accepted clinical and radiological follow-up. Eight years later mammography revealed in the same breast a 10-mm nodule containing microcalcifications, which was not evident at physical examination. The patient underwent a lumpectomy. Intraoperative histology was positive for breast carcinoma and complete axillary clearance was performed. Histological examination revealed a lobular invasive breast carcinoma and the presence of micrometastasis in one of the 23 removed lymph nodes. The patient was given radiotherapy to the breast and axilla and tamoxifen. At present, one year after the appearance of the primary tumor, she is free of disease. Based on this case report we suggest an eclectic approach in the management of patients with axillary metastasis from occult breast cancer, depending on the clinical, pathological and biological findings.
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Ouldamer L, Cayrol M, Vital M, Fièvre C, Druelles M, Arbion F, Body G, Lévêque J, Fritel X. Axillary lymph node metastases from unknown primary: A French multicentre study. Eur J Obstet Gynecol Reprod Biol 2018. [PMID: 29518639 DOI: 10.1016/j.ejogrb.2018.02.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim of the study was to investigate the management and prognosis of axillary cancers from unknown primaries (CUPax). METHODS We included all patients with lesions described as axillary nodal metastases from an unknown primary referred to four French tertiary breast cancer centres between January 1988 and December 2012. The inclusion criteria comprised: no sign of primary breast cancer on clinical examination nor on imaging (mammography, ultrasonography and breast MRI) and no primary tumour identified elsewhere. RESULTS CUPax represented 1.8% of all metastatic axillary lymphadenopathies in our institutions. The overall survival rate was 71%, and 16.7% of patients had secondary inflammatory breast cancer signalling a posteriori that CUPax originated from the breast. Factors that favourably affected survival according to univariate analysis were: histological type of non specific adenocarcinoma (versus other types, p = 0.02), only one lymph node involved (versus several, p = 0.04), a normal CA153 serum-level (p = 0.02), no distant metastasis at initial assessment (p = 0.02), no secondary distant metastasis (p = 0.005) and radiotherapy to the ipsilateral breast/chest wall/lymph nodes (p = 0.04). On multivariate analysis including these factors, a histological type of non-specific adenocarcinoma (p = 0.03) and distant metastases (p = 0.03) were identified as independent factors affecting survival. CONCLUSION We believe that these results will shed light on current investigations and treatment of this rare entity.
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Affiliation(s)
- Lobna Ouldamer
- Department of Gynecology, Centre Hospitalier Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044, Tours, France; INSERM unit 1069, 10 boulevard Tonnellé, 37044, Tours, France; François Rabelais University, 2 boulevard Tonnellé, 37044, Tours, France.
| | - Marie Cayrol
- Department of Gynecology, Centre Hospitalier Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044, Tours, France; François Rabelais University, 2 boulevard Tonnellé, 37044, Tours, France
| | | | - Claire Fièvre
- Department of Gynecology, Centre Hospitalier Universitaire de Poitiers, 6 rue de la milétrie, 86021, Poitiers cedex, France
| | - Marion Druelles
- Department of Gynecology, Centre Hospitalier Universitaire Anne de Bretagne, 16 boulevard de Bulgarie, BP 90347, 35203, Rennes Cedex 2, France
| | - Flavie Arbion
- Department of Pathology, Centre Hospitalier Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044, Tours, France
| | - Gilles Body
- Department of Gynecology, Centre Hospitalier Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044, Tours, France; François Rabelais University, 2 boulevard Tonnellé, 37044, Tours, France
| | - Jean Lévêque
- Department of Gynecology, Centre Hospitalier Universitaire Anne de Bretagne, 16 boulevard de Bulgarie, BP 90347, 35203, Rennes Cedex 2, France
| | - Xavier Fritel
- Department of Gynecology, Centre Hospitalier Universitaire de Poitiers, 6 rue de la milétrie, 86021, Poitiers cedex, France
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Couder F, Schmitt C, Treilleux I, Tredan O, Faure C, Carrabin N, Beurrier F, Chopin N. [Axillary lymph node metastases with an occult breast: About 16 cases from a cohort of 7770 patients]. ACTA ACUST UNITED AC 2015; 43:588-92. [PMID: 26257298 DOI: 10.1016/j.gyobfe.2015.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 06/22/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Isolated axillary lymph node metastases is an unusual clinical presentation of breast carcinoma. We studied its different issues. METHODS This study is a follow-up study of 16patients, treated between 1996 and 2012, presenting with axillary metastases with an occult breast carcinoma, which could not be identified by physical examination nor by a conventional imaging or a breast MRI. Clinical characteristics, histological analysis, treatment, monitoring and five-year survival rate were studied. RESULTS The incidence of this kind of breast cancer was 0.20%. A breast MRI was performed in 75% of the patients. The histology of these tumors showed a rate of hormono-sensibility of 50% and an HER2 overexpression of 44%. Sixty-nine percent of the patients had no breast surgery or radiotherapy; global five-year survival rate for these women was 77.4%±11.5. CONCLUSION The survival rates of this study should lead the practitioner to choose a less aggressive breast therapy. Moreover, the histological characteristics explain the high metastatic potential of these tumors, and relate them to the HER2+ subclass of gene expression patterns of breast carcinomas.
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Affiliation(s)
- F Couder
- Département de chirurgie oncologique, centre Léon-Bérard, centre de lutte contre le cancer Lyon et Rhône-Alpes, 28, rue Laënnec, 69373 Lyon cedex 08, France
| | - C Schmitt
- Département de chirurgie oncologique, centre Léon-Bérard, centre de lutte contre le cancer Lyon et Rhône-Alpes, 28, rue Laënnec, 69373 Lyon cedex 08, France
| | - I Treilleux
- Département d'anatomo-pathologie, centre de lutte contre le cancer Lyon et Rhône-Alpes, Lyon, France
| | - O Tredan
- Département d'oncologie médicale, centre de lutte contre le cancer Lyon et Rhône-Alpes, Lyon, France
| | - C Faure
- Département de chirurgie oncologique, centre Léon-Bérard, centre de lutte contre le cancer Lyon et Rhône-Alpes, 28, rue Laënnec, 69373 Lyon cedex 08, France
| | - N Carrabin
- Département de chirurgie oncologique, centre Léon-Bérard, centre de lutte contre le cancer Lyon et Rhône-Alpes, 28, rue Laënnec, 69373 Lyon cedex 08, France
| | - F Beurrier
- Département de chirurgie oncologique, centre Léon-Bérard, centre de lutte contre le cancer Lyon et Rhône-Alpes, 28, rue Laënnec, 69373 Lyon cedex 08, France
| | - N Chopin
- Département de chirurgie oncologique, centre Léon-Bérard, centre de lutte contre le cancer Lyon et Rhône-Alpes, 28, rue Laënnec, 69373 Lyon cedex 08, France.
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Fayanju OM, Stoll CRT, Fowler S, Colditz GA, Jeffe DB, Margenthaler JA. Geographic and temporal trends in the management of occult primary breast cancer: a systematic review and meta-analysis. Ann Surg Oncol 2013; 20:3308-16. [PMID: 23975301 DOI: 10.1245/s10434-013-3157-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Management of occult primary breast cancer (OPBC), including the role of magnetic resonance imaging (MRI), is controversial. We conducted a pooled analysis of OPBC patients and a meta-analysis of MRI accuracy in OPBC in order to elucidate current practices. METHODS A literature search yielded 201 studies. Patient-level data for clinically/mammographically OPBC from studies published after 1993 and from our institution were pooled; logistic regression examined associations between patient/study data and outcomes, including treatments and recurrence. We report adjusted odds ratios (OR) and 95 % confidence intervals (95 % CI) significant at 2-tailed p < 0.05. Meta-analysis included data for patients who received MRIs for workup of clinically/mammographically OPBC. We report pooled sensitivity and specificity with 95 % CIs. RESULTS The pooled analysis included 92 patients (15 studies [n = 85] plus our institution [n = 7]). Patients from Asia were more likely to receive breast surgery (OR = 5.98, 95 % CI = 2.02-17.65) but not chemotherapy (OR = 0.32, 95 % CI = 0.13-0.82); patients from the United States were more likely to receive chemotherapy (OR = 13.08, 95 % CI = 2.64-64.78). Patients from studies published after 2003 were more likely to receive radiotherapy (OR = 3.86, 95 % CI = 1.41-10.55). Chemotherapy recipients were more likely to have distant recurrence (OR = 9.77, 95 % CI = 1.10-87.21). More patients with positive MRIs received chemotherapy than patients with negative MRIs (10 of 12 [83.3 %] vs 5 of 13 [38.5 %]; p = 0.0414). In the MRI-accuracy meta-analysis (10 studies, n = 262), pooled sensitivity and specificity were 96 % (95 % CI = 91-98 %) and 63 % (95 % CI = 42-81 %), respectively. CONCLUSIONS OPBC management varied geographically and over time. We recommend establishing an international OPBC patient registry to facilitate longitudinal study and develop global treatment standards.
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Fayanju OM, Jeffe DB, Margenthaler JA. Occult primary breast cancer at a comprehensive cancer center. J Surg Res 2013; 185:684-9. [PMID: 23890400 DOI: 10.1016/j.jss.2013.06.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 05/29/2013] [Accepted: 06/07/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Management of occult primary breast cancer (OPBC), that is, breast cancer that first presents through regional nodal or distant disease without clinical or mammographic evidence of disease in the breast, has been controversial and inconsistent. Here, we review OPBC patients treated at our institution. METHODS We conducted a retrospective review of women diagnosed with a first primary breast cancer between March 1999 and September 2010 to identify patients who presented with isolated axillary lymphadenopathy proven to be histologically consistent with primary breast malignancy but had no evidence of a breast mass on physical examination, mammography, or ultrasound. Descriptions of treatments received, recurrence, morbidity, and mortality as of October 2012 are reported. RESULTS Of 5533 patients reviewed, seven (0.1%) patients were identified. The median age was 65 y old (range, 40-72), and the median length of follow-up was 86 mo (range, 42-124). Four patients underwent modified radical mastectomy, one patient had a lumpectomy and axillary lymph node dissection, and two patients had axillary lymph node dissection without breast surgery. Four patients received adjuvant radiation therapy. All seven patients received chemotherapy. Three patients received endocrine therapy, and two patients received anti-HER2 therapy. At the last follow-up, all seven patients were alive with no evidence of disease. CONCLUSIONS Although there was some variation in the management of OPBC at our institution, our patients had excellent outcomes after multimodal treatment. Our results support a curative intent approach to the treatment of OPBC and illustrate the need for individualized treatment algorithms based on tumor biology and extent of the disease at diagnosis.
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Montagna E, Bagnardi V, Rotmensz N, Viale G, Cancello G, Mazza M, Cardillo A, Ghisini R, Galimberti V, Veronesi P, Monti S, Luini A, Raviele PR, Mastropasqua MG, Goldhirsch A, Colleoni M. Immunohistochemically defined subtypes and outcome in occult breast carcinoma with axillary presentation. Breast Cancer Res Treat 2011; 129:867-75. [PMID: 21822638 DOI: 10.1007/s10549-011-1697-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 07/22/2011] [Indexed: 12/29/2022]
Abstract
The aim of this study is to evaluate the outcome of occult breast cancer (OBC) in patients with axillary presentation overall and according to the immunohistochemically defined tumour subtypes. We reviewed information on 15,490 consecutive primary breast cancer patients, who underwent surgery at the European institute of oncology between September 1997 and December 2008. Patients with OBC were compared with an equal number of patients with small invasive breast carcinomas (pT1) observed at the same institution during the same period, matched for year of surgery, age, nodal status and biological features. Eighty patients with OBC (study group) and 80 patients with early breast cancer (control group) were identified. There was no significant difference in the disease-free survival (5 years DFS 66 vs. 68% P = 0.91) and the overall survival (5 years OS 80 and 86% P = 0.99) between the OBC and control groups. A statistically significant worse outcome was observed within the group of OBC for patients with more than four involved lymph nodes and with triple negative tumours. The outcome of OBC patients is comparable with that of matched patients with small sized breast cancer. High risk of relapse and death was observed in OBC patients with triple negative tumours and extensive nodal involvement.
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Affiliation(s)
- Emilia Montagna
- Division of Medical Oncology, Department of Medicine, Unit Research of Medical Senology, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy.
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Pentheroudakis G, Lazaridis G, Pavlidis N. Axillary nodal metastases from carcinoma of unknown primary (CUPAx): a systematic review of published evidence. Breast Cancer Res Treat 2010; 119:1-11. [PMID: 19771506 DOI: 10.1007/s10549-009-0554-3] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Accepted: 09/10/2009] [Indexed: 11/25/2022]
Abstract
Axillary lymph node metastases from adeno carcinoma or poorly differentiated carcinoma of unknown primary (CUPAx) represent a rare clinical entity without consensus on its biology, management and outcome. We systematically reviewed published CUPAx series and identified 24 retrospective studies enrolling 689 patients from 1975 till 2006. CUPAx affected women at a mean age of 52 years, 66% of whom post-menopausal harbouring low-volume (N1, 48%) or high-volume (52%) nodal disease from ductal adenocarcinoma (83%). Among a total of 446 patients managed with mastectomy, a small breast primary was identified histologically in 321 (72% of cases). Hormone receptor protein expression was observed in 40-50% of cases, while HER2 overexpression in 31%. CUPAx patients were managed with axillary lymph node dissection coupled to mastectomy (59%), primary breast irradiation (26%) or observation (15%). Observation was associated with high locoregional relapse rates (42%) and risk of metastatic spread. Mastectomy or radiotherapy provided locoregional disease control in 75-85% of cases, while adjuvant systemic therapy was associated with a nonsignificant trend for improved survival in few series. Five-year survival ranged from 59.4 to 88% at a median follow-up of 62 months (mean 5-year survival 72%), with axillary tumour burden being the pivotal prognostic factor. CUPAx is associated with similar presentation, biology and outcome to resected node-positive overt breast cancer and should be treated accordingly.
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Abstract
PURPOSE Breast carcinoma presenting with axillary lymphadenopathy and no clinical or radiological evidence of a primary tumor is a rare presentation. We aimed to examine the management of the breast by observation, radiation therapy, or mastectomy. METHODS AND MATERIALS Departmental records from 1979 to 1996 of unknown primary presentations and cases of T0N1-2M0 breast carcinoma were reviewed to find cases of occult breast carcinoma presenting as axillary lymphadenopathy with no clinical or imaging evidence of a primary tumor. RESULTS There were 6047 presentations of breast carcinoma with 20 cases of occult breast carcinoma meeting the criteria. The breast was treated by observation in 6 cases, mastectomy in 2 cases, and radiotherapy to the intact breast in 12 cases. Eighty-three percent of patients (5 of 6 patients) who had observation of the breast had a local recurrence, compared to 25% who had radiotherapy to the intact breast (3 of 12 patients) and 0% who had a mastectomy (0 of 2 patients). The median recurrence-free survival was 7 months in patients who had observation of the breast, compared to 182 months in patients who had local treatment. Three of the 6 patients who underwent breast observation have died whereas 1 of the 14 who had local treatment have died, with a mean follow-up of 73 months. It was found that patients having observation of the breast had a poorer recurrence-free survival (p = 0.003) and overall survival (p = 0.05) compared to those having local treatment of the breast. CONCLUSIONS Patients with such a presentation should have a complete physical examination, mammography, ultrasound, and MRI of the breasts. If there remains no evidence of a primary tumor, an axillary dissection should be carried out and the breast treated by radiotherapy or mastectomy. Observation of the breast is not a recommended option.
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Affiliation(s)
- F Foroudi
- Westmead Hospital, Westmead, Australia.
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GALLO ANGELO, CANZONIERI VINCENZO, TUMOLO SALVATORE, ZARRELLI ANTONIO, SCARABELLI CARLO, CARBONE ANTONINO. Ovarian Metastatic Adenocarcinoma Occurring as Bilateral Axillary Metastases Associated with Mastitis. J Gynecol Surg 1997. [DOI: 10.1089/gyn.1997.13.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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10
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Read NE, Strom EA, McNeese MD. Carcinoma in Axillary Nodes in Women with Unknown Primary Site?Results of Breast-Conserving Therapy. Breast J 1996. [DOI: 10.1111/j.1524-4741.1996.tb00130.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Merson M, Andreola S, Galimberti V, Bufalino R, Marchini S, Veronesi U. Breast carcinoma presenting as axillary metastases without evidence of a primary tumor. Cancer 1992; 70:504-8. [PMID: 1617600 DOI: 10.1002/1097-0142(19920715)70:2<504::aid-cncr2820700221>3.0.co;2-t] [Citation(s) in RCA: 91] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Sixty cases of axillary metastases from clinically occult breast cancer were analyzed. All cases had histologic evidence of metastatic nodes compatible with breast carcinoma. METHODS Thirty-three patients underwent breast surgery at the time of histologic diagnosis of the axillary metastases, 6 patients were treated with radiation therapy to the breast, and 17 patients did not receive any immediate treatment of the breast carcinoma (9 of these subsequently had a primary breast carcinoma) during the follow-up. Thirty-seven of 60 patients underwent adjuvant therapy (29 underwent chemotherapy and 8 underwent tamoxifen therapy). From the histologic point of view, the number of metastatic nodes was 1 in 13 patients, 2 to 3 in 10 patients, and 4 or more in 23 patients; the number of metastatic nodes was not evaluable in 14 cases. Invasion was extranodal in 92% of cases. Eighty-six percent of cases were histologically classified as Grade 3 according to Bloom and Richardson. RESULTS The 5-year and 10-year survival rates were 77% and 58%, respectively. The comparison between the survival curves of the patients treated with immediate surgery/radiation therapy and of the patients whose cases were followed-up without treatment to the breast showed no difference. Adjuvant treatments did not improve prognoses. CONCLUSIONS The coexistence of a minimal (or unidentifiable) primary carcinoma with an extensive involvement of axillary nodes and a predominance of the undifferentiated histologic type, together with an unexpectedly good prognosis, makes this type of presentation an interesting example of a dissociated host resistance.
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Affiliation(s)
- M Merson
- Istituto Nazionale Tumori, Milan, Italy
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Ellerbroek N, Holmes F, Singletary E, Evans H, Oswald M, McNeese M. Treatment of patients with isolated axillary nodal metastases from an occult primary carcinoma consistent with breast origin. Cancer 1990; 66:1461-7. [PMID: 2207996 DOI: 10.1002/1097-0142(19901001)66:7<1461::aid-cncr2820660704>3.0.co;2-z] [Citation(s) in RCA: 117] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The records of 42 patients who had axillary metastases compatible with a clinically occult breast primary were reviewed. Forty patients had mammography performed as part of their evaluations. Mastectomy yielded the primary tumor in one of 13 patients; biopsy yielded positive results in one of five. Among the 29 patients who did not undergo mastectomy, 16 received breast irradiation, and 13 were simply observed for signs of the primary tumor. For the patients who did not undergo mastectomy, the 5-year actuarial risk for appearance of a primary was 17% in the irradiated group versus 57% in the nonirradiated group (P = 0.06). Patterns of failure are correlated with stage and local and systemic therapy. The results affirm our belief that patients with axillary metastases histologically consistent with breast tumor should be treated identically to patients with similar nodal stages and proven breast primaries.
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Affiliation(s)
- N Ellerbroek
- Department of Clinical Radiotherapy, University of Texas, Anderson Cancer Center, Houston 77030
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